New Zealand restructured its health system in 1992 with the aim
of achieving greater levels of assessment and accountability in the
publicly funded health sector. A committee was established specifically
to advise the minister of health on the kinds, and relative priorities,
of health services that should be publicly funded. One of its projects
has been to develop standardised sets of criteria to assess the extent
of benefit expected from elective surgical procedures. These have been
developed with the help of professional advisory groups using a
modified Delphi technique to reach consensus. So far the committee has
developed criteria for cataract surgery, coronary artery bypass
grafting, hip and knee replacement, cholecystectomy, and tympanostomy
tubes for otitis media with effusion. These criteria incorporate both
clinical and social factors. Use of priority criteria to ensure
consistency and transparency regarding patients' priority for surgery
is required for access to a dedicated NZ$130m (£57m; US$90m) pool of
money, created to help eliminate surgical waiting lists and move to
booking systems. The criteria will also be used in surgical outcome
studies, currently in the planning phase.
Introduction
In this article we describe a national project, sponsored jointly
by New Zealand's National Advisory Committee on Health and Disability
and the four regional health authorities, to develop standardised
priority assessment criteria for elective surgical procedures. Under
the auspices of this project, criteria were developed for cataract
extraction, coronary artery bypass graft surgery, hip and knee
replacement, cholecystectomy, and tympanostomy tubes for otitis media
with effusion. These criteria are used (a) to assess
patients' relative priority for surgery, (b) to ensure
consistency and transparency in the provision of surgical services
across New Zealand, and (c) to provide a basis for
describing the kinds of patients who will or will not receive surgery
under various possible levels of funding.
New Zealand health reforms
| New Zealand health reforms |
| Fourteen area health boards were replaced with four regional
health authorities, which purchase publicly funded health and
disability services. The National Advisory Committee on Health and
Disability was created to advise the minister of health on the kinds of
services to be purchased with public funds - and their priority.
The Ministry of Health (formerly Department of Health) is responsible
for macro policymaking and funding. Inpatient services are provided
predominantly by crown health enterprises (hospitals and affiliated
institutions), which are managed as businesses and are state owned.
A complete split exists between funding, purchasing, and provision of
services.
Since this paper was prepared for publication the New Zealand health
reforms have themselves been drastically reformed. Future papers in the
BMJ will describe these changes. |
As part of a sweeping overhaul of its economy and social
structure, New Zealand implemented major reforms of its healthcare
system in 1992 (see box).(1) These reforms can be viewed as
a response to the imperatives described by Relman in his 1988 editorial
in the New England Journal of Medicine announcing the
arrival of the era of assessment and accountability in health
care.(2) Relman called for a "revolution" in how health
care is provided and paid for, endorsing a proposal put forth by Elwood
in the same journal just a few months earlier.(3) Elwood
described the problem like this:
Too often, payers, physicians, and health
care executives do not share common insights into the life of the
patient. We acknowledge that our common interest is the patient,
but we represent that interest from such divergent, even conflicting,
viewpoints that everyone loses perspective. As a result, the health
care system has become an organism guided by misguided choices; it is
unstable, confused, and desperately in need of a central nervous system
that can help it cope with the complexities of modern
medicine.
The New Zealand health reforms represent an effort to
provide such a central nervous system. Elwood proposed that the
healthcare system should routinely collect detailed clinical
information concerning (a) the quantity and kinds of
services provided, (b) the numbers and kinds of patients
receiving those services, and (c) the outcomes
experienced by those patients. Recognition of the need for such
assessment data and for better channels of communication constituted a
major rationale for the restructuring. At the same time, the contract
mechanism was seen as a useful method for ensuring provider
accountability.
National health committee
A major component of the legislation under which the
healthcare system was restructured was the creation of a National
Advisory Committee on Core Health and Disability Support Services,
since renamed the National Advisory Committee on Health and
Disability - and known as the national health committee. This
committee is charged with providing independent advice to the minister
of health (independent, in particular, of the Ministry of Health)
concerning the "kinds, and relative priorities, of public health
services, personal health services, and disability services that
should, in the committee's opinion, be publicly
funded."(4)
Early in its tenure the national health committee came under
considerable pressure to develop a relatively simple list of services
depicting what was in or out of the "core" of services that would
be publicly funded. From the outset, however, the committee has taken a
different approach. It has preferred to define eligibility for services
in terms of clinical practice guidelines or explicit assessment
criteria which depict the circumstances under which patients are likely
to derive substantial health benefit from those services, bearing in
mind competing claims on resources. Thus, for example, patients could
reasonably expect to receive coronary bypass graft surgery at the
taxpayer's expense if (and only if) their clinical circumstances were
commensurate with a likelihood of substantial benefit from that
procedure.
The waiting list problem
Long waiting lists for elective surgery have been a nagging issue
that long predated the formation of the ministry, regional health
authorities, and the national health committee. Based on one of its
early commissioned reports,(5) the national health committee
recommended that surgical services should move away from a system of
waiting lists and toward a system of specific booking times, so that
patients would know (within reasonable limits) when they would receive
their operation. In addition, the committee called for greater
transparency and consistency in the process used to decide priority for
elective surgery.(6)
The minister, the ministry, and the regional health authorities
accepted the national health committee's advice, including the
replacement of waiting lists with booking systems. As a step toward
realising this goal, the regional health authorities and national
health committee cosponsored a national project to put in place the
tools needed to assess the extent of patients' overall priority or
urgency for surgery. These priority criteria would reflect primarily
the benefit expected from surgery. Priority would generally be given to
patients with the greatest likely benefit.
Thus, the ethical framework under which the project was conducted was
largely utilitarian in nature, with the principal goal being to achieve
the maximum possible health gain with the available funds. The national
health committee had formally embraced the philosophy of maximising
expected benefit in one of its early reports.(6)
The national priority criteria project
A six member project steering group was constituted, consisting of
representatives of the national health committee (DCH and ACH) and the
surgical services managers of the four regional health authorities.
Ministry of Health officials were briefed regularly but were not
members of the steering group. The stated objective of the project was:
To develop national criteria for assessing
the priority which should be given to patients for medical and surgical
procedures.... The national priority criteria will serve the
following purposes:
(1) To ensure that the process used to define
priority is fair and consistent across New Zealand.
(2) To permit
the assessment and comparison of need, case mix, and severity.
(3)
To assist the regional health authorities in developing new booking
strategies, including target booking times for patients with defined
levels of priority.
(4) To permit comparison of waiting times
across regional health authorities.
(5) To ensure that social
values are integrated into the decision making process in an
appropriate and transparent manner.
(6) To provide the framework
for the national health committee to define maximum acceptable waiting
times for patients with defined levels of priority, as well as core
levels of each service.
(7) To make possible national studies on
the health outcomes experienced by patients who do or do not receive
the services.
| Project methods |
| A summary of the relevant literature was prepared by project
staff.
Professional advisory groups were constituted for each procedure,
consisting of two or three specialists and surgeons from each of the
four regions and two general practitioners.
A two stage Delphi process preceding each professional advisory
group meeting was open to all relevant specialists and surgeons in New
Zealand (about 20-30 clinicians participated for each procedure, not
counting members of the professional advisory groups).
Criteria were selected and initial weights agreed at meetings of
the professional advisory groups. The draft criteria were pilot tested
and their weights recalibrated based on the results. |
The box above summarises the approach taken to develop the
criteria.
Progress to date
Five sets of standardised assessment criteria were developed for
elective surgical procedures under the auspices of the project.
Numerical scores were assigned to each of the multiple levels of
severity on each criterion; relevant scores on each criterion were
added together to form a total score. These multiple factor, additive
systems are known as linear models. Such models are well known to
outperform unaided clinical judgment on a wide variety of diagnostic
and predictive tasks.(7-9)
The procedures covered are (in order of development):
(1) Cataract extraction
(2) Coronary artery bypass graft surgery
(3) Hip and knee replacement
(4) Cholecystectomy
(5) Tympanostomy tubes for otitis media with effusion
| Table 1 - Priority criteria for cataract surgery
(maximum score 100) |
| Clinical features |
| Score |
| Visual
acuity | 6/9 or
better | 6/12 | 6/18 | 6/24 | 6/36 | 6/60 | Count fingers/hand
movements |
| 6/9 or better | 0 | 1 | 2 | 3 | 4 | 5 | 6
|
| 6/12 |
| 7 | 8 | 9 | 10 | 11 | 12
|
| 6/18 |
|
| 14 | 15 | 16 | 17 | 18
|
| 6/24 |
|
|
| 21 | 22 | 23 | 24
|
| 6/36 |
|
|
|
| 28 | 29 | 30
|
| 6/60 |
|
|
|
|
| 35 | 36 |
| Count fingers/hand
movements |
|
|
|
|
|
| 40 |
| Glare |
| None | 0 |
| Mild-moderate | 5 |
| Severe | 10 |
| Ocular comorbidity
(eg age related
macular degeneration, chronic simple glaucoma) |
| None | 0 |
| Mild-moderate | 5 |
| Severe | 10 |
| Ability to work, care for dependants, or work
independently |
| Not threatened or not applicable | 0 |
| Not threatened but more difficult | 2 |
| Threatened but not
immediately | 6 |
| Immediately threatened | 15 |
| Extent of impairment in visual function (eg
reading, recognising faces, seeing steps or kerbs, watching TV,
driving, and reading traffic signs) |
| None | 0 |
| Mild | 5 |
| Moderate | 10 |
| Severe | 20 |
| Other
substantial disability (eg hearing loss, uses wheelchair) |
| No | 0 |
| Yes | 5 |
| Total
score |
Table 1 shows the criteria for cataract extraction and
table 2 those for hip and knee replacement. All criteria were subject
to a pilot study to assess the extent of correspondence between the
total priority score and global clinical judgments of urgency. A
description of the development of the criteria for coronary artery
bypass grafting together with their pilot study are described in part 2
of this article. Additional information on the pilot studies is
available on the BMJ's Internet web site
(www.bmj.com).
| Table 2 - Priority criteria for major joint replacement
(maximum score 100)
|
| Clinical features | Score |
| Pain
(40%) |
| Degree (patient must be on maximum medical
therapy at time of rating): |
| None | 0
|
| Mild: slight or occasional pain; patient has not altered patterns
of activity or work | 4 |
| Mild-moderate: moderate or frequent
pain; patient has not altered patterns of activity or work | 6
|
| Moderate: patient is active but has had to modify or give up
some activities because of pain | 9 |
| Moderate-severe: fairly
severe pain with substantially limited activities | 14 |
| Severe:
major pain and serious limitation | 20 |
| Occurrence: |
|
| None
or with first steps only | 0 |
| Only after long walks (30
minutes) | 4 |
| With all walking, mostly day pain | 10
|
| Significant, regular night pain | 20
|
| Functional activity
(20%) |
| Time walked: |
|
| Unlimited | 0
|
| 31-60 minutes (eg longer shopping trips to mall) | 2 |
| 11-30
minutes (eg gardening, grocery shopping) | 4 |
| 2-10 minutes (eg
trip to letter box) | 6 |
| less than 2 minutes or indoors only (more or
less house bound) | 8 |
| Unable to walk | 10 |
| Other
functional limitations (eg putting on shoes, managing stairs, sitting
to standing, sexual activity, recreation or hobbies, walking aids
needed): |
| None | 0 |
| Mild | 2 |
| Moderate | 4
|
| Severe | 10
|
| Movement and deformity (20%)
|
| Pain on examination (overall results are both active and passive
range of motion): |
| None | 0 |
| Mild | 2 |
| Moderate | 5
|
| Severe | 10 |
| Other abnormal findings (limited to
orthopaedic problems eg reduced range of motion, deformity, limp,
instability, progressive x ray findings): |
| None | 0
|
| Mild | 2 |
| Moderate | 5 |
| Severe | 10
|
| Other factors
(20%) |
| Multiple joint disease: |
| No, single
joint | 0 |
| Yes, each affected joint mild: moderate in
severity | 4 |
| Yes, severe involvement (eg severe rheumatoid
arthritis) | 10 |
| Ability to work, give care to dependants, live
independently (difficulty must be related to affected joint): |
| Not
threatened or difficult | 0 |
| Not threatened but more
difficult | 4 |
| Threatened but not immediately | 6
|
| Immediately threatened | 10 |
| Total
score |
Social factors considered in setting priorities
As well as clinical criteria, several social factors were
discussed during the course of this project and, to some extent,
incorporated within the priority criteria. The most important of these
were (a) age, (b) work status,
(c) whether patients were caring for dependants or
threatened with the loss of their own independence, and
(d) time spent on the waiting list.
Age
There was substantial disagreement among project participants
about the appropriate role of patients' age in assessing the expected
benefit from surgery. From a practical perspective, many participants
considered age to be a roughly reliable guide to the overall extent of
comorbidity experienced by patients, which in turn affects the extent
of benefit that can be expected from surgery. However, others were
concerned that, even if this is true on average, use of age as a factor
in deciding priority for surgery could result in denying services to
many elderly patients who would benefit as much as (or more than)
younger patients. In the end, age was incorporated in just one set of
criteria: those for coronary artery bypass graft surgery. The rationale
for its inclusion here was that this type of surgery has direct
implications for life expectancy as well as quality of life, whereas
the other surgical procedures directly affect only quality of life. The
professional advisory group on coronary artery bypass grafting believed
that life prolongation becomes progressively less important for elderly
patients compared with the importance of quality of life. Accordingly,
the group developed a formula to adjust downward, beginning at age 70,
the weights assigned to variables associated with improvements in life
expectancy (see BMJ web site for details.)
Threat to independence, care of dependants, ability to work
During the process of identifying the factors currently used by
clinicians to make judgments of expected benefit project participants
acknowledged that clinicians take into account whether (and to what
extent) patients' clinical conditions threaten their ability to work,
care for dependants, and live independently. Substantial discussion
was held on this topic at each professional advisory group meeting,
with clinicians generally agreeing that these factors should be
represented as priority criteria. Nevertheless, a certain degree of
misgiving was usually noted about incorporating these social factors.
To address this issue, the national health committee sponsored two
public hearings, one on each major island, specifically devoted to
discussing the appropriateness of including these factors in the
assessment of urgency and priority for elective surgery. A stratified
random sample of the public in each community and patients with the
relevant conditions were recruited to provide their perspectives.
Clinicians from the local area and members of the professional advisory
groups also attended. Although no definitive resolution was achieved,
the results of the hearings were regarded by observers from the
national health committee and regional health authorities as supporting
the inclusion of these factors provided they are given relatively
little weight compared to clinical factors.
Time spent on waiting list
The length of time spent waiting for the procedure also proved a
contentious and difficult issue. Many clinicians favoured inclusion of
such a factor on grounds that the "simple act of waiting" should
warrant some consideration. However, this concern was balanced by the
fact that, if waiting time were incorporated, the inevitable result
would be that in many cases less impaired patients would be operated on
before more impaired patients. In the end, "time spent waiting" was
excluded from the criteria, mainly because the principal tenet of the
criteria is that they reflect the degree of clinical (and social)
likely benefit associated with the clinical condition, not time spent
waiting.
Minister of health's announcement
On 8 May 1996 the minister of health, Jenny Shipley, announced the
creation of a new NZ$130m (£57m; US$90m) fund with the express purpose
of reducing waiting times and clearing waiting lists. Access to the
funds is contingent on the use of explicit clinical priority criteria,
such as, but not limited to, those developed during this project.
Professional and public response is generally positive
Response to the new waiting list initiative has been generally
positive. In particular, the response from doctors has been largely one
of relief that thousands of patients on waiting lists will now be
provided with surgery who would not have received it without these new
funds. News coverage has also been generally favourable. The capital's
Dominion described the move as another "welcome step
toward reducing waiting lists for non-urgent surgery in a responsible
way, instead of resorting to the bad old practice of throwing money at
a problem and hoping for the best....The new system is designed to
ensure that people with the biggest need and greatest potential benefit
will have their surgery first, that the same rules apply throughout New
Zealand.... All this is light years ahead of rationing surgery by
making people wait indefinitely for it, and with marked regional
variations."(10)
In part 2 of this article we describe in more detail our experience
developing, testing, and implementing the priority criteria for
coronary artery bypass graft surgery.
We thank the many clinicians who participated in this project
without whose support this project could not have been completed
successfully.
Funding: National Advisory Committee on Health and Disability
and the four regional health authorities.
Conflict of interest: None.
References
1 Ashton T. From evolution to revolution:
restructuring the New Zealand health system. Health Care
Analysis 1993;1:57-62.
2 Relman A S. Assessment and accountability: the third revolution
in medical care. N Engl J Med 1988;319:1220-2.
3 Elwood P M. Outcomes management: a technology of patient
experience. N Engl J Med 1988;318:1549-56.
4 Health and Disability Act 1993, as amended 1995; Sec 8, par 2,
p5.
5 Fraser G, Alley P, Morris R. Waiting lists and waiting
times: their nature and management. Wellington: National
Advisory Committee on Core Health and Disability Support Services,
1993.
6 National Advisory Committee on Core Health and Disability
Support Services. Second annual report. Wellington:
National Advisory Committee on Core Health and Disability Support
Services, 1993.
7 Dawes R M, Corrigan B. Linear models in decision making.
Psychol Bull 1974;81:95-106.
8 Meehl P K. Clinical versus statistical prediction: a
theoretical analysis and a review of the evidence. Minneapolis:
University of Minnesota Press, 1954.
9 Tversky A, Kahneman D. Judgment under uncertainty:
heuristics and biases. Cambridge: Cambridge University Press,
1982.
10 Editorial. Dominion. 1996; 10 May:8.
(Accepted 16 October 1996)
National Advisory Committee on Health and Disability,
Ministry of Health,
Wellington,
New Zealand
David C
Hadorn, manager, special projects
Andrew C
Holmes, senior medical
adviser
Correspondence to: Dr Hadorn.
